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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License
�ttiry9/� Lic. Class Exp. Date *1
CIY r 4 n�0/Oa3
Date �- � Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Date ISignature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
p rformance of the work for which this permit is issued.
l) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier NATIONAL UNI(:N F: Policy No. 705309
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisiond6f Section 3700 of the Labor
Code, -I shy I` I fgrt�iwith comply' Iw ih thosg proJisi�ns.
'Date: ;�.. 1 r Applicant`` ~'� ""`"°��'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his ,
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if_
work is not commenced within 180 days from date of issuance rof _sU7h
permit, or cessation of work for 180 days will subject permit to cancellation.,....•_
I certify that I have read this application and state that the above inforniati is
correct. I agree to comply with all City, and State laws relating to the h)uilding tt,`AA
construction, and hereby authorize representatives of this City to enttNr! upon Evil
the above-mentioned property_for inspection purposes.
Signature (Owner/�Agent)� ✓ Date --�t F
PERMIT #
BUILDING PERMIT "MS
-121 t
DATE VALUATION��A ��j we LOT �� TRACT 30023
JOB SITE
ADDRESS eye .�3 1 s ��! tAsi
APN
7.•270-016
OWNER
CONTRACTOR / DESIGNER / EN (NEER
X1EAL& QUIRTA, LLC
SHE..AROA4:
60-311 :1'.1MAM. PPP-,iiWAY
81 -260 AMUR 62
LA c2UINTA CA 922S3
IWERUAL
CA 92883
(909)833.6996
MW 6876
USE OF PERMIT
-T"55,
X71- J IAN 4320A '.t'./. A,S. iL. 'S:k O,I 111J'EZ VF./
DICLUDF; lE:tIAXT WALLA POOL, SPA OR DR1VE't AY APPROACH •75%
PMDUCT. TO WC FEE FOR MUI;rIPLP-ISSUANCE OF ..,AML PLAN TYPE
-2
r, USTOM CONSi'RUC71ON 11013.00 SP
POtt4;WPATIO 1 00I SF
(3AARAWCARPC?FtT 488,00 Si•
9911M ND, COST OF CJONSMU MON
16112W.2.0
PKRWf:b E
CONSTRUCTION FEE 101.000.418.OW $854.50
PLAN C;1 YXK F#Z 101-000-433-318 $174.37
MECHANICAL ANICAIs 1'ER 101-000-421-000 4150.00
Lf, ECTI IC:A,1,. FRE 101-OAQw420-000 S118.36'
PLUMBINO FFM 101-000-4,19-000 4146.75
STRCYNO BA C)TIOM FEE RESW 7131-000-241-000
ORA,DDIO F'LF 101-000-4-23-000
T.1WELOPER IMPACT FE -E, $7,405m
SUB-TCfFPJ;1C0N1,TfR'Ut"c: 1702+i•AKID PLAN LM.CIC.
$3,803.91
t I51,R&PAt FUS
$01A)
TOT AL ITUNUT FETES DUE NOW
1
TWFIFR Z,4a t s: i DATE!
By f 7D
AjZ FI E
IN P
R
I v
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
71Return
Air
Steel
Combustion Air
Roof Deck
a
Exhaust Fans
O.K to Wrap
(..30-67 3 Zz
F.A.U.
Framing a.-
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
1J3
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Q
Encapsulation
Gas Piping
'
Gas Test
Appliances
Final
Final
Utility Notice (Gas)'
ELECTRICAL APPROVALS
Temp. Power Pole-
Underground Conduit
Rough Wiring �2 —
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) i
COMMENTS:
'
4DMainiero, Smith and Associates, Inc.
Planning / Civil Engineering / Land Sunw-ving
777 East Tahquitz Canyon Way, Suite 301 / Palm Springs, California 92262-6784
Telephone (760) 320-9811 / FAX (760) 323-7893 - e-mail info@ma'nierosmith.com - www.mainierosmith.com
May 7, 2003
Department of Building and Safety
CITY OF LA QUINTA
78-495 Calle Tampico
La Quinta, CA 92253
Re: Form Certification
Tract No. 30023-2
Construction Sequence 1-E
Gentlemen:
- _ qEC j
r• .
This letter is to verify that the following building forms have been checked for elevation and
horizontal location by Mainiero, Smith and Associates, Inc. and found to be in substantial
conformance with the approved Precise Grading Plans. Finished floor elevations for lots 122 —
126 and lots 16.4 - 166 are as follows:
Very truly y urs,
Sip LAND SUNG
Steven J Van, L.S. 6500 STEVENJ.VAN FO
v 70
SJV:tt REG.EXPG
cc: - Hector Guzman, Engineering Department f N0.650D �Q
Mike Groessl, Shea Homes OF
CA
Pad Elevations
Lot #
Address
Plan
Field
Difference
122
81699 Brittlebush Ln
430.80
430.75
-0.05
123
81711 Brittlebush Ln
429.70
429.62
-0.08
124
81723 Brittlebush Ln
429.00
428.98
-0.02
125
81735 Brittlebush Ln
428.30
428.27
-0.03
126
81747 Brittlebush Ln
427.60
427.62
+0.02
164
6041.9 Chelsea Ct
427.80
427.84
+0.04
165
60397 Chelsea Ct
42830
428.33
+0.03
166
60375 Chelsea Ct
428.50
428.52
+0.02
Very truly y urs,
Sip LAND SUNG
Steven J Van, L.S. 6500 STEVENJ.VAN FO
v 70
SJV:tt REG.EXPG
cc: - Hector Guzman, Engineering Department f N0.650D �Q
Mike Groessl, Shea Homes OF
CA